32A-176 (7) BP-2021-2144
66 BRIDGE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-176-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2144 PERMISSION'S HEREBY GRANTED TO:
Project# DEMO Contractor: License:
Est. Cost: 12000 DOUGLAS THAYER 107699
Const.Class: Exp.Date:04/07/2022
Use Group: Owner: NORTHAMPTON HISTORICAL SOCIETY THE
Lot Size (sq.ft.)
Zoning: URC Applicant: DOUGLAS THAYER
Applicant Address Phone: Insurance:
P O BOX 60322 (413)530-4785 6HUB-9F79609
FLORENCE, MA 01062
ISSUED ON:11/05/2021
TO PERFORM THE FOLLOWING WORK:
INTERIOR DEMO
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House# Foundation:
Driveway Final: Final: Final: Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
[ ECEIVE[)
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The Commonwealth of Massahuset U 2 2021
W Office of Public Safety and Inspect ns
Massachusetts State BuildingCode(780 R
)DEPT.OF WI DING INSPECTIONS
Building Permit Application for any Building other than a O, e-or Twor iyINv@I4 _..___
(This Section For Official Use Only)
Building Permit Number:8P-41-.21 y'tDate Applied: Building Official:
SECTION 1:LOCATION
No,and Teet City/Town 17 Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building 0 Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other Specify: trl Prrta l n Pykdlt fib n
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 41
Is an Independent Structural Engineering Peer Review required? Yes 0 No 13(
Brief Description of Proposed Work:
Veluovn l a all L vl3PvNit PA, I v-PI S for q'Xelora �� )76,po5{s ye PA,Ivt !f
('ov1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
•
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) •
i )
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 1-2❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1)4 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ IIA 0 IIB 0 IIIA 0 IIIB 0 IV 0 VA 0 VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site 0
Public Check if outside Flood Zone 0 Indicate municipal A trench will not be P
Private 0 or indentify Zone: or on site system 0 required or trench or specify:
permit is enclosed 0 Vf ePC����N
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission lieview Process:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes or No Yes 0 No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
taarit Sand fvS V i - y 66 II - L. Sa„dP�s�l�cs�,,,c No
. or uilpl6,►,
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
--)o«hletS thulfy Po for 607a a N ein(re /IA 0/6' do?6
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals)
Od Ia5 Thq�ry (Ili _SR_ (InS DOW�I4S, h�'�fre 6r�(l,(o,,.
Name �gistran Telephone No. e-mail address Registration Number
t ex 0D7a a Flovewc. ✓k�- 010 6?
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
DTW
Company Name
00ugla5 than-Lc CS -- )07 6'4/41
Name olerson Responsi a for Construction License No. and Type if Applicable
eo 3o,c 6O1 ?i pIoveitce it k 0/0 6,
Street Address City/Town State Zip
- - VP/ -51a 97 $ S O043L43 tho yr, 0 1nial. co41
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes No a
SECTION 12 CONSTRUCTION COSTS AND PERMIT F E
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 12 000. Building Permit Fee=Total uctio ost x (insert here
2.Electrical $ appropriate m iipal factor) $ .
3.Plumbing $ �WQ1
4.Mechanical (HVAC) $ Note:Minimum f =$ tact municipality)
5.Mechanical (Other) $ Enclose check payable
6.Total Cost $ 12 000 (contact municipality)and write check number here 4000
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in tl 's
application is true and accurate to the best of my knowl ge and understanding. //0�l
DC4( s 7"ha e✓ � C V13- SIo- Y7 _.Please rint and 'gn name Title Telephone No. Date
ro pax 601,22 plo eNcP AA d me;
Street Address City/Town State Zip Email Address
r 1 i /Ls/at
' tr
Municipal Inspector to fill out this section upon application approval: •
Name� ��`�
Date
City of Northampton
h E4
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Massachusetts !r�
w X
" �' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal BuildingJ�. �>
Northampton, MA 01060 6°, 0
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: \joi I1e
QPC)41
The debris will be transported by:
Name of Hauler: PCkptS -1114 ekt
Signature of Applicant: A Date: 1f
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 congress Street,Sake 100
i)
Boston,MA 02114-2017
WWW.ntass.gov/dia
Workers t'ompensatinn Insurance Affidavit:Buliders/ContractorilElectricians/Plumbers.
TO BE Ell 411.1 WITH THE PERMITTING AUTHORITY.
ADDlitallt I nformatioa Please Print I.eeihiv
Nitrite(Husinesalhgainzattortilnillvidual); 1)1245 7
Address'. QA. 0 01 0
.,.... „„..,.. _ ___________
City/State/21r._, Fkre,',lc. JtA Phone#:
An pm Sr ent ivioyerf Check the appropriate holt: ;1;project(required):
' I ,A ISM a triivkryor with cts,, :employees(full main/pan-time), 7. D Nevi ConStrUctictil
II lam a sok proprietor or partnership and have no employees working far me in ' r 8.,. [3 Remodeling
any capacity„[No*edicts'comp.insurance required"
9. ).4 Demolition
30 I am a homeowner doing all wort myself.[No workers'conp.insurance minimal'
I 0[3 Building addition
I am a homeowner and will it his*comments to conduct all work on ray property. 1 will
emote that all contractors either have workers compensation itninance or are sole I I.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
Sej I am a general contractor and I have hired the sob-corstraerairs listed on the attached short
' 1 3.EjRoof repairs
Thew soh-contractors have employee*and It workers'comp.til%UllitiCe.:
14,°Other
6.E3 We aft a oorporienni and it.*officeto have exercised their right of exemption per ARIL e.
152,*1(4),and we have no employees.No WOliceVA'comp.insurance requited.}
*Any applicant that chocks bas#1 mug also fill out the;IicPini below Shearing their workerc compentation policy information.
t Itioneowners who submit this afr/on indicating they arc doing all work and then hire onititie conimetor*nuat smbreat a new affidavit indicating such.
tContractors that check this bok must attached an additional sheet showing the name of the sub-cmuracisies and suite whether or not thaw oolitic*Low
employee,' ft Ow',Alf b-cfatitra,nioN ha yr employees,they must provide their workers'.,,,,,nr.policy number
I am an employer that is providing workers'compensation insurance for my employees. Brit",is the policy and Job site
Information.
Insurance Company Name: 71--Ct vpiev5 -
Policy#or Self-ins.Lie.#: 6/ tff .- F-7? ‘oci Expiration Date:
Job Site Address: o 6 01,;:d CyC 5.4-- City/State/Zip:ALI VO-A-4447 k71 i14-
Attach$Copy of the workers'compensalion policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to SI,500.00
andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$2.50.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA tir insurance
coverage verification
I do hereby c. i 'under I ins amdpenahies of perjury that the information provided aboye Is tee and correct.
Date: // 47 i3Z‘ I
Signature: s:.. i I--'- ,
Phone#. Vt - 510 '' Y7 i r
. . ,
Official use only. Do not write in this area,to be completed by city or town official I
City or Town: PermitiLieense# r
Issuing Authority(circle one): [
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector .,
6.Other
Contact Person: Phone
. .
. .